Prehospital Stroke Care Research Articles

Current status and issues of prehospital care for stroke from nationwide questionnaire survey to the fire departments

Current status and issues of prehospital care for stroke from nationwide questionnaire survey to the fire departments

Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018.

The 2018 update of the Canadian Stroke Best Practice Recommendations for Acute Stroke Management, 6th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by healthcare providers and system planners caring for persons with very recent symptoms of acute stroke or transient ischemic attack. The recommendations are intended for use by a interdisciplinary team of clinicians across a wide range of settings and highlight key elements involved in prehospital and Emergency Department care, acute treatments for ischemic stroke, and acute inpatient care. The most notable changes included in this 6th edition are the renaming of the module and its integration of the formerly separate modules on prehospital and emergency care and acute inpatient stroke care. The new module, Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care is now a single, comprehensive module addressing the most important aspects of acute stroke care delivery. Other notable changes include the removal of two sections related to the emergency management of intracerebral hemorrhage and subarachnoid hemorrhage. These topics are covered in a new, dedicated module, to be released later this year. The most significant recommendation updates are for neuroimaging; the extension of the time window for endovascular thrombectomy treatment out to 24 h; considerations for treating a highly selected group of people with stroke of unknown time of onset; and recommendations for dual antiplatelet therapy for a limited duration after acute minor ischemic stroke and transient ischemic attack. This module also emphasizes the need for increased public and healthcare provider's recognition of the signs of stroke and immediate actions to take; the important expanding role of paramedics and all emergency medical services personnel; arriving at a stroke-enabled Emergency Department without delay; and launching local healthcare institution code stroke protocols. Revisions have also been made to the recommendations for the triage and assessment of risk of recurrent stroke after transient ischemic attack/minor stroke and suggested urgency levels for investigations and initiation of management strategies. The goal of this updated guideline is to optimize stroke care across Canada, by reducing practice variations and reducing the gap between current knowledge and clinical practice.

Characteristics of Prehospital Acute Stroke Care in an Urban Setting: Pilot Data from the Pre-hospital Rapid Evaluation via Ambulance Lead Emergency Remote Telemedicine (PRE-ALERT) Study (P1.210)

Characteristics of Prehospital Acute Stroke Care in an Urban Setting: Pilot Data from the Pre-hospital Rapid Evaluation via Ambulance Lead Emergency Remote Telemedicine (PRE-ALERT) Study (P1.210)

Abstract WP244: Current Status and Issues in Prehospital Care for Stroke in Japan: A Nationwide Fire Department Questionnaire Survey

Background and purpose: In the rapidly aging society of Japan, improvement of the emergency medical care system for stroke is an urgent concern. In prehospital care for stroke, appropriate triage, selection of the delivery facility, and decreased transport time contribute directly to prognosis. The standard treatment for acute ischemic stroke (AIS) has changed dramatically. With the introduction of new thrombectomy devices, proper placement of comprehensive stroke centers (CSCs) should be reconsidered. Accordingly, a nationwide survey is needed to develop an efficient prehospital care system. The aim of this study was to elucidate problems in prehospital care for stroke in Japan, using a nationwide fire department (FD) questionnaire survey. Materials and methods: We conducted a questionnaire survey of 733 FDs in Japan with the cooperation of the Japanese Society of Emergency Medicine and the Emergency Planning Office of the Fire and Disaster Management Agency. The questionnaires evaluated utilization status of the Prehospital Stroke Life Support (PSLS) protocol and prehospital stroke scale (PSS), awareness of standard treatment with new devices, information on delivery facilities and transportation, use of information and communication technology (ICT), and the retraining system for paramedics. Results: Data obtained from 664 FDs (91%) were analyzed. The PSLS protocol and PSS were used by 47.2% and 59.6%, respectively. Surprisingly, only 35.6% of FDs had knowledge about the latest treatment for AIS, and half of the FDs did not have an opportunity to learn about treatment. The proportion of FDs with a CSC in their jurisdictions was decreased in rural areas compared with urban areas (19.2% vs. 49.8%). However, helicopter transportation and ICT were not adequately utilized even in rural areas. Only half of the FDs urged paramedics to attend a PSLS course. Conclusion: We demonstrated problems with prehospital care for stroke in Japan using a nationwide FD questionnaire survey. Placement of CSCs, adequacy of the transportation system, and communication between physicians and paramedics should be reevaluated.

Abstract TP219: Can Pre-hospital Intervention Improve Rural Stroke Care?

Background: In the stroke belt, local rural hospitals have reported 29 - 32% tissue plasminogen activator (tPA) treatment within 60 minutes for ischemic strokes. Since 2008, telemedicine has improved the door to treatment time from 120+ minutes to 70 minutes. A six month pilot program was initiated to determine the feasibility of a pre-hospital intervention to reach the American Stroke Association (ASA) target of 50% treatment within 60 minutes. Nine rural hospital sites were designated as Stroke Ready Hospitals (SRHs). Local emergency medical service (EMS) providers to these sites received additional education to evaluate and transport suspected stroke patients to the SRH in their area. The study also evaluated the early acute hospital patient care for improvements in treatment rates and data reporting at each SRH site. Hypothesis: Within six months, the SRHs will have 30-50% improvement rates in pre-notification by their local EMS providers and these will correspond to decreased triage time. Methods: This study assessed the benefit of early pre-notification by local EMS providers on decreased time to treatment and improved triage time as an improved process of care after implementation in nine SRH designated sites. To measure improvements in time to treatment and treatment rates, we compared time and treatment rates before (baseline was 11 months pre-study) and after study implementation in the same hospital sites. Results: A total of 6,049 transports were made by the EMS services with 117 patients suspected as strokes. A medical public safety answering point (PSAP) communication network provided stability in EMS data acquisition and stroke code notification to SRHs. The study showed improvements in mean triage and transport time vs. baseline (30.7 vs. 74 min, n=48 and n=22, respectively), Door to CT time vs. baseline (21 vs. 26 min, n=151 and =218, respectively) and Door to tPA time vs. baseline (65 vs. 78 min, n=13 and =22, respectively). While the ASA goal of 50% was not met, the % of treated ≤ 60 min increased from baseline at 24.8 to 38%. Pilot study code stroke % pre-notification increased from 38 to 69%. Conclusions: Pre-hospital intervention with local EMS providers improved pre-notification, first medical contact to CT time and the arrival time to treatment.

Abstract WP221: A Pragmatic Computer Algorithm Successfully Matches De-identified Regional Quality Improvement Database Records and Emergency Medical Services Records

Introduction: Linking prehospital data from emergency medical services (EMS) patient care records with hospital-based data in quality improvement databases, such as the American Heart Association’s Get With the Guidelines (GWTG)-Stroke database, can help inform initiatives that aim to improve both prehospital and hospital-based acute stroke care. However, inconsistent data collection, discrete systems, and privacy concerns prevent simple data merging of prehospital and hospital-based databases. Hypothesis: A simple, pragmatic computer algorithm using probabilistic matching can successfully link EMS data with hospital-based quality improvement data. Methods: A retrospective pilot study was performed that matched hospital data from GWTG-Stroke, a regional quality improvement database, and prehospital data from a single municipal fire-based EMS provider agency that responds to all 9-1-1 calls in a large US city with 15 primary and comprehensive stroke centers participating in GWTG-Stroke data collection. Using data for patients with confirmed stroke arriving via EMS from July to December 2013, we implemented a rule-based probabilistic matching algorithm that incorporated patient age, sex, time of hospital arrival +/- 30 minutes, and destination hospital to match de-identified records between the GWTG-Stroke and EMS databases. A subset of records at one stroke center was audited to verify successful matches. Python (Python Software Foundation, Beaverton, Oregon) was used to facilitate analysis. Results: Among 328 patients with confirmed stroke arriving by EMS, a probabilistic matching algorithm successfully linked the prehospital and hospital records for 300 (91%). The 28 unmatched records were due to typographical errors or missingness of entered data. Of 40 algorithm-matched records audited at one stroke center for accuracy, 40 (100%) had been matched correctly. Conclusions: A simple algorithm using patient age, sex, time of hospital arrival, and destination hospital successfully matched greater than 90% of de-identified prehospital and hospital records. Leveraging high fidelity database matching can facilitate future work that links prehospital and hospital stroke interventions to patient outcomes.

Abstract 47: Impact of EMS Field-telestroke With Hand-held Ipads on IV-tpa Therapy for Stroke

Introduction: Reducing the Door-to-Needle (D2N) time to IV-tPA has been shown to improve outcomes after acute ischemic stroke. Pre-hospital Telestroke using Mobile Stroke Units has been shown to reduce D2N times but the number of patients treated are underpowered to show improvement in stroke outcome. With deployment in urban areas near multiple comprehensive stroke centers and costs averaging $1M to purchase and $1M to operate annually, it is unlikely that Mobile Stroke Units will exert a major impact on the broader population of stroke victims. Hypothesis: Bringing Telestroke expertise to the patient by utilizing Advance Stroke Life Support (ASLS)- trained EMS crews equipped with hand-held iPADS for videoconferencing in the field with their Medical Control could enhance patient assessment and reduce D2N times for IV-tPA in acute stroke. Methods: Field-Telestroke training of 243 EMS personnel from 6 community squads associated with a 332-bed acute care Primary Stroke Center was conducted in 2q 2016 and included ASLS Certification, education on Stroke Protocols and videoconferencing in the field with the hospital’s Medical Control, and the use of HIPPA-compliant hand-held iPADs. A retrospective analysis of transports from July 2014- July 2016 pre-implementation and July 2016-June 2017 post-implementation included Stroke Alert process times of Door-to-CT completion (DCT) and D2N. Results: Pre-hospital use of Field-Telestroke from July 2016-June 2017 was associated with a shorter average DCT of 10.7 vs 34.5 minutes and shorter D2N time for IV-tPA therapy of 41 minutes vs 50 minutes with standard pre-hospital notification. Overall IV-tPA utilization from July 2016-June 2017 (12.7%, 26/204) was non-significantly increased from baseline July 2014- June 2016 (10.6%, 50/473, p=0.43). Conclusions: The use of Field- Telestroke was associated with faster DCT and D2N times for IV-tPA therapy. Field-Telestroke by ASLS-trained EMS squads is a promising low-cost approach to deliver high quality pre-hospital stroke care to communities.

Prehospital stroke care, a narrative review.

Stroke is a leading cause of disability in the United States and current treatment for stroke is limited to two modalities with well-defined time restraints. The prehospital setting is a significant and relatively easy setting for innovation in stroke care, as the most clinical decisions are made within the first several hours of symptom onset. In this review, we look at recent innovations in improving prehospital care for acute stroke including the conception of mobile stroke units, the ongoing development of stroke models for emergency providers, barriers to prehospital care, and the innovation of new telephone applications. Although there are notable improvements in acute stroke care, additional research is needed to further improve on current models and technologies.

Time Gain Needed for In-Ambulance Telemedicine: Cost-Utility Model.

BackgroundStroke is a very time-sensitive pathology, and many new solutions target the optimization of prehospital stroke care to improve the stroke management process. In-ambulance telemedicine, defined by live bidirectional audio-video between a patient and a neurologist in a moving ambulance and the automated transfer of vital parameters, is a promising new approach to speed up and improve the quality of acute stroke care. Currently, no evidence exists on the cost effectiveness of in-ambulance telemedicine.ObjectiveWe aim to develop a first cost effectiveness model for in-ambulance telemedicine and use this model to estimate the time savings needed before in-ambulance telemedicine becomes cost effective.MethodsCurrent standard stroke care is compared with current standard stroke care supplemented with in-ambulance telemedicine using a cost-utility model measuring costs and quality-adjusted life-years (QALYs) from a health care perspective. We combine a decision tree with a Markov model. Data from the UZ Brussel Stroke Registry (2282 stroke patients) and linked hospital claims data at individual level are combined with literature data to populate the model. A 2-way sensitivity analysis varying both implementation costs and time gain is performed to map the different cost-effective combinations and identify the time gain needed for cost effectiveness and dominance. For several modeled time gains, the cost-effectiveness acceptability curve is calculated and mapped in 1 figure.ResultsUnder the base-case scenario (implementation cost of US $159,425) and taking a lifetime horizon into account, in-ambulance telemedicine is a cost-effective strategy compared to standard stroke care alone starting from a time gain of 6 minutes. After 12 minutes, in-ambulance telemedicine becomes dominant, and this results in a mean decrease of costs by US –$30 (95% CI –$32 to –$29) per patient with 0.00456 (95% CI 0.00448 to 0.00463) QALYs on average gained per patient. In over 82% of all probabilistic simulations, in-ambulance telemedicine remains under the cost-effectiveness threshold of US $47,747.ConclusionsOur model suggests that in-ambulance telemedicine can be cost effective starting from a time gain of 6 minutes and becomes a dominant strategy after approximately 15 minutes. This indicates that in-ambulance telemedicine has the potential to become a cost-effective intervention assuming time gains in clinical implementations are realized in the future.

The PRE-hospital Stroke Treatment Organization.

Background The PRE-hospital Stroke Treatment Organization was formed in 2016 as an international consortium of medical practitioners involved in pre-hospital treatment of patients with acute stroke. Aims PRE-hospital Stroke Treatment Organization's mission is to improve stroke outcomes by supporting research and advocacy for pre-hospital stroke treatment in Mobile Stroke Units. PRE-hospital Stroke Treatment Organization will provide a platform to enhance collaborative research across the spectrum of acute stroke management in the pre-hospital setting. PRE-hospital Stroke Treatment Organization will also facilitate the appropriate proliferation and distribution of Mobile Stroke Units by providing a forum for professional communication, resource for public education, and stimulus for government, industry, and philanthropic support. Summary of review In this "white paper", we describe the evidence supporting pre-hospital stroke treatment, progress to date, practical issues such as application in various environments and staffing, planned research initiatives, and organizational structure. Conclusions PRE-hospital Stroke Treatment Organization is not-for-profit, with membership open to anyone involved (or hoping to become involved) in pre-hospital stroke care. PRE-hospital Stroke Treatment Organization has a Steering Committee comprised of members from Europe, U.S., Canada, Australia, and other regions having a Mobile Stroke Unit in operation. PRE-hospital Stroke Treatment Organization convenes satellite meetings for membership at the International Stroke Conference and European Stroke Congress each year to address the PRE-hospital Stroke Treatment Organization mission. The first research collaborations agreed upon are to: (1) develop a list of common data elements to be collected by all Mobile Stroke Unit programs and entered into a common research database, and (2) develop a protocol for investigating the natural history of hyper-acute Intracerebral Hemorrhage.

Berlin prehospital or usual delivery of acute stroke care - Study protocol.

Rationale Prehospital stroke care in specialized ambulances increases thrombolysis rates, reduces alarm-to-treatment times, and improves the prehospital triage. Preliminary analyses suggest cost-effectiveness. However, scientific proof of better functional outcome compared to usual care is still lacking. Aim To prove better functional outcomes after deployment of the Stroke Emergency Mobile compared to regular ambulances. Sample size estimates A sample size of 686 patients will be required in each arm (Stroke Emergency Mobile group vs. regular care) to detect a difference regarding the primary outcome with 80% power at a two-sided significance level of 0.05. Methods and design This is a pragmatic, prospective study with blinded outcome assessment. Primary outcome will be functional status as defined by modified Rankin Scale score three months after the incident event. We will include cerebral ischemia patients within a predefined catchment area in Berlin, Germany. The study population consists of patients who might be candidates for acute recanalizing treatments, with onset-to-alarm time ≤4 h, symptoms not resolved at time of ambulance arrival, and able to walk without assistance prior to the qualifying incident. About 45% of Stroke Emergency Mobile dispatches are expected to be handled by regular ambulances, since Stroke Emergency Mobile will be already in operation creating the control group. Primary outcome Functional outcome after three months measured by the modified Rankin Scale over the entire range. Discussion The results will inform decision makers on the effectiveness of Stroke Emergency Mobile.

Abstract WP246: Probabilistic Linkage of De-identified Prehospital and Hospital Data for Stroke Patients Achieves Similar Match Rates to Manual Linkage

Background: Acute ischemic stroke patients that are recognized by Emergency medical services (EMS) receive expedited care are more likely to receive t-PA. In order to study the continuum of acute stroke care and ensure accurate case ascertainment, prehospital and inpatient medical records must be linked. We tested the feasibility of probabilistic matching to link prehospital EMS data and in-hospital records using data from existing de-identified registries, and compared results to manual linkage. Methods: A registry containing all EMS-transported suspect or confirmed stroke cases in Kent County, Michigan was used to identify subjects discharged from either of two primary stroke centers with a diagnosis of stroke or TIA. The registry contains EMS data obtained through direct query of EMS electronic medical record systems which is linked manually to hospital data using patient identifiers (name, date of birth). For the probabilistic match, de-identified data for EMS suspected stroke transports from the EMS information system (EMSIS) was provided by the county medical control authority. Probabilistic linkage between hospital stroke discharges and EMSIS data was done using LinkPlus software. Age, sex, transport agency, and date of service were used as matching variables. Probabilistic match rates were compared to manual registry match rates among EMS suspect stroke cases using a chi square test. Results: Over a 6-month period in 2015, 172 hospital-confirmed stroke and TIA patients arrived by EMS at the target hospitals. Over the same period, 214 EMS suspect stroke cases were identified from the registry and 199 EMS suspect stroke cases were identified in EMSIS. Probabilistic linkage correctly matched 64.5% (111/172) of confirmed strokes to prehospital records in EMSIS, which was not significantly different from the manual registry match rate of 73.8% (127/172, p=0.24). There were 16 cases in the manual match that were missed by the probabilistic match: 5 (2.9%) due to age mismatch and 11 (6.4%) were missing from the EMSIS data. The remaining non-matched cases represented EMS missed stroke cases. Conclusion: Probabilistic matching of de-identified pre-hospital and hospital data is a feasible approach for the evaluation of prehospital stroke care.

Fire Engine Support and On-scene Time in Prehospital Stroke Care - A Prospective Observational Study.

Introduction On-scene time (OST) previously has been shown to be a significant component of Emergency Medical Services' (EMS') operational delay in acute stroke. Since stroke patients are managed routinely by two-person ambulance crews, increasing the number of personnel available on the scene is a possible method to improve their performance. Hypothesis Using fire engine crews to support ambulances on the scene in acute stroke is hypothesized to be associated with a shorter OST. All patients transported to hospital as thrombolysis candidates during a one-year study period were registered by the ambulance crews using a case report form that included patient characteristics and operational EMS data. Seventy-seven patients (41 [53%] male; mean age of 68.9 years [SD=15]; mean Glasgow Coma Score [GCS] of 15 points [IQR=14-15]) were eligible for the study. Forty-five cases were managed by ambulance and fire engine crews together and 32 by the ambulance crews alone. The median ambulance response time was seven minutes (IQR=5-10) and the fire engine response time was six minutes (IQR=5-8). The number of EMS personnel on the scene was six (IQR=5-7) and two (IQR=2-2), and the OST was 21 minutes (IQR=18-26) and 24 minutes (IQR=20-32; P =.073) for the groups, respectively. In a following regression analysis, using stroke as the dispatch code was the only variable associated with short (<22 minutes) OST with an odds ratio of 3.952 (95% CI, 1.279-12.207). Dispatching fire engine crews to support ambulances in acute stroke care was not associated with a shorter on-scene stay when compared to standard management by two-person ambulance crews alone. Using stroke as the dispatch code was the only variable that was associated independently with a short OST. Puolakka T , Väyrynen T , Erkkilä E-P , Kuisma M . Fire engine support and on-scene time in prehospital stroke care - a prospective observational study. Prehosp Disaster Med. 2016;31(3):278-281.

Abstract TP307: Promising Practices to Improve the Quality of Pre-Hospital Stroke Care Transitions

Introduction: Between 2012-2015 the Centers for Disease Control and Prevention’s (CDC) Paul Coverdell National Acute Stroke Program (PCNASP) funded 11 state health departments to improve the quality of stroke care across the continuum, beginning with the initial signs and symptoms of stroke through the transition from hospital to post-hospital setting. Hypothesis: We assessed the hypothesis that PCNASP quality improvement activities enhanced the quality of pre-hospital stroke care transitions. Methods: We conducted 72 semi-structured telephone interviews with stakeholders of the 11 PCNASP grantees, including program administrators, epidemiologists, quality improvement consultants, partners, emergency medical services (EMS) and hospital staff. Using grounded theory (Glaser and Strauss), we developed and applied a coding scheme to the interview transcripts to identify emerging themes related to pre-hospital quality improvement activities. Results: Many PCNASP grantees provided training and support for EMS and hospital staff that improved calling of a stroke code team and recognition of stroke, improved EMS pre-notifications about suspected stroke patients, advanced hospital holding of CT scanners in anticipation of suspected stroke patients, and reduced door-to-CT and door-to-needle time. PCNASP grantees had different approaches to balancing timeliness and quality of care. Some grantees developed statewide destination protocols that required EMS to bypass proximate hospitals for certified stroke care hospitals. Other grantees had challenges implementing statewide destination protocols because EMS agencies were decentralized with local authority to determine where to transport patients. In other cases, grantees promoted a “drip and ship” model where EMS transported patients to proximate hospitals for IV-tPA and then to a primary stroke center and focused on increasing the reach of stroke telemedicine. Conclusion: PCNASP grantees developed promising practices to improve the quality of pre-hospital stroke care transitions that accounted for their unique state context. These approaches may become the basis for best practices for improving pre-hospital transitions of stroke care across the nation.

Abstract WP247: Paramedic Perspectives on Prehospital Stroke Care: A Qualitative Analysis

Introduction: Ischemic stroke patients who arrive by emergency medical service (EMS) receive faster emergency department evaluations and improved rates of thrombolytic treatment. However, EMS stroke recognition and compliance with prehospital stroke quality measures are inconsistent. We hypothesized that EMS stroke care is influenced by a complex interaction of knowledge, beliefs, and system-level variables that influence behavior. Methods: Focus groups of paramedics from a single urban/suburban county were assembled to discuss their experiences identifying and transporting stroke patients. Focus groups were conducted using a semi-structured interview format and audio recorded. Transcripts of focus groups were qualitatively analyzed to identify themes, subthemes, and patterns of paramedic responses. The Clinical Practice Guidelines Framework provided the initial coding scheme, which was modified during the coding process by three coders using grounded theory methods, who came to consensus on which codes to apply. Results: Three focus groups (n=13) were conducted to reach theme saturation. Overall, paramedics reported high confidence in clinical gestalt for assessing stroke patients and a strong desire to “do the right thing,” but were unfamiliar with published guidelines. Paramedics identified variability in the clinical presentations of stroke, inadequate or inconsistent hospital guidance, and lack of feedback regarding care as principle barriers to ideal prehospital stroke care. Participants reported conflicting hospital guidance regarding the appropriate time frame for a high priority transport and hospital prenotification. Feedback regarding final diagnosis was viewed as critical for developing improved clinical acumen. Direct to CT protocols were cited as an effective way to integrate EMS into hospital stroke response. Conclusion: In this qualitative analysis, paramedics expressed a desire for clear, hospital-directed guidance and consistent feedback regarding outcomes for suspected stroke patients.

Abstract 179: Functional Outcomes of Pre-hospital Stroke Thrombolysis Compared to Conventional Care; the Stroke Emergency Mobile (STEMO) Project

Background: Specialized CT-equipped stroke ambulances can shorten time to intravenous thrombolysis (IVT) in acute ischemic stroke. Although efficacy of thrombolytic treatment is known to be time-sensitive, effects of pre-hospital thrombolysis on functional outcomes have not yet been evaluated. Methods: We compared outcomes of all consecutive stroke patients who received thrombolysis during the same period cared for either by the Berlin Stroke Emergency Mobile (STEMO) or within conventional care (normal ambulance and in-hospital thrombolysis). Treatment and outcomes were documented in prospective registries. Patients who lived at home without assistance prior to their stroke were included. Primary outcome was modified Rankin Scale (mRS) ≤1 at 3 month. Secondary outcome was 3-month mortality. Outcomes were adjusted in multivariable regression for demographics, co-morbidities and stroke severity. Results: From Feb. 5, 2011 to Mar 5, 2015, 427 patients were treated on STEMO and 513 in conventional care. 303 (mean age: 71y, female gender: 48%, median NIHSS: 7) and 357 (mean age: 70y, female gender: 36%, median NIHSS: 7) of them had lived at home without assistance pre-stroke, respectively. Mean onset to treatment time was 34 minutes shorter in STEMO care (96±60 vs. 130±56min). The primary outcome of mRS≤1 was observed in 167 (55%) and 168 (47%) patients (p=0.039); 17 (6%) vs 38 (11%) had died (p=0.02), respectively. Adjusted odds ratios were favorable for STEMO care: OR 1.56 (95%-CI: 1.11-2.20; p=0.01) for mRS≤1 and OR 0.50 (95%-CI: 0.26-0.98; p=0.04) for death. Conclusions: The data suggest that earlier start of IVT by specialized prehospital stroke care leads to improved outcome.

Brain Imaging Using Mobile CT: Current Status and Future Prospects.

Computed tomography (CT) is an invaluable tool in the diagnosis of many clinical conditions. Several advancements in biomedical engineering have achieved increase in speed, improvements in low-contrast detectability and image quality, and lower radiation. Portable or mobile CT constituted one such important advancement. It is especially useful in evaluating critically ill, intensive care unit patients by scanning them at bedside. A paradigm shift in utilization of mobile CT was its installation in ambulances for the management of acute stroke. Given the time sensitive nature of acute ischemic stroke, Mobile stroke units (MSU) were developed in Germany consisting of an ambulance equipped with a CT scanner, point of care laboratory system, along with teleradiological support. In a radical reconfiguration of stroke care, the MSU would bring the CT scanner to the stroke patient, without waiting for the patient at the emergency room. Two separate MSU projects in Saarland and Berlin demonstrated the safety and feasibility of this concept for prehospital stroke care, showing increased rate of intravenous thrombolysis and significant reduction in time to treatment compared to conventional care. MSU also improved the triage of patients to appropriate and specialized hospitals. Although multiple issues remain yet unanswered with the MSU concept including clinical outcome and cost-effectiveness, the MSU venture is visionary and enables delivery of life-saving and enhancing treatment for ischemic and hemorrhagic stroke. In this review, we discuss the development of mobile CT and its applications, with specific focus on its use in MSUs along with our institution's MSU experience.

PreSSUB II: The prehospital stroke study at the Universitair Ziekenhuis Brussel II.

RationaleStroke is a time-critical medical emergency requiring specialized treatment. Prehospital delay contributes significantly to delayed or missed treatment opportunities. In-ambulance telemedicine can bring stroke expertise to the prehospital arena and facilitate this complex diagnostic and therapeutic process.AimsThis study evaluates the efficacy, safety, feasibility, reliability and cost-effectiveness of in-ambulance telemedicine for patients with suspicion of acute stroke. We hypothesize that this approach will reduce the delay to in-hospital treatment by streamlining the diagnostic process and that prehospital stroke care will be improved by expert stroke support via telemedicine during the ambulance transportation.DesignPreSSUB II is an interventional, prospective, randomized, open-blinded, end-point, single-center trial comparing standard emergency care by the Paramedic Intervention Team of the Universitair Ziekenhuis Brussel (control) with standard emergency care complemented with in-ambulance teleconsultation service by stroke experts (PreSSUB).Study OutcomesThe primary efficacy endpoint is the call-to-brain imaging time. Secondary endpoints for the efficacy analysis include the prevalence of medical events diagnosed and corrected during in-ambulance teleconsultation, the proportion of patients with ischemic stroke receiving recanalization therapy, the assessment of disability, functional status, quality of life and overall well-being. Mortality at 90 days after stroke is the primary safety endpoint. Secondary safety analysis will involve the registration of any adverse event. Other analyses include assessment of feasibility and reliability and a health economic evaluation.

LEADERSHIP, INNOVATION AND ENGAGEMENT IN QUALITY IMPROVEMENT IN THE AMBULANCE SERVICES CARDIOVASCULAR QUALITY INITIATIVE: CROSS SECTIONAL STUDY

IntroductionClinical leadership and organisational culture are important contextual factors for successful Quality Improvement (QI) programmes. The relationship between these and with organisational performance is complex and poorly understood. We aimed...

Prehospital reversal of warfarin-related coagulopathy in intracerebral hemorrhage in a mobile stroke treatment unit.

Warfarin-related intracerebral hemorrhage (ICH) accounts for 15% to 20% of all intraparenchymal hemorrhages and is associated with a much higher mortality than spontaneous ICH.1 Although rapid (ie, within 2 hours of onset) reversal of warfarin effect has been advocated,2,3 significant delays in initiation of therapy and correction of international normalized ratio are common.2 A mobile stroke treatment unit (MSTU) can deliver prehospital stroke care and can shorten the time to thrombolytic therapy in patients with ischemic stroke.4,5 MSTU can also deliver other therapies in acute neurological emergencies. Cleveland Clinic in collaboration with the Emergency Medical Services of the City of Cleveland implemented an MSTU starting July 18, 2014. We report on the prospectively collected data through August 31, 2014. The on-board MSTU team consists of a registered nurse, paramedic, emergency medical technician, and a computed tomography (CT) technologist. A cerebrovascular specialist evaluates the patient via telemedicine (InTouch RP-Xpress. Santa Barbara, CA), whereas a neuroradiologist remotely evaluates images obtained by a portable CT scanner (CereTom, Neurologica Corporation, Danvers, MA). Point-of-care laboratory testing routinely performed includes coagulation profile (coaguChek XS Pro, Roche Diagnostics, Indianapolis, IN), complete blood count (pocH 100i hematology analyzer, Sysmex Corporation, Kobe, Japan), and blood chemistry (iSTAT System, Abbott …